21480 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
^/$� BuildingPProjectt'��Identification
,, ; A... PERMIT NO.
BUBIiV"SS`1 E. `�kil-'' Uti �.S S- 241) L/ �3 �- 0 00 21 � z 21480
rte Ije/� ams: one: A A
)04, -F Aw, CITY Ca'•CUPERTINO-BUILDING DIVISICNJ
1Ann
f_ Llc,"°� APPLICATION I PERMIT
lM+$ E. 39 2 33 2 BUILDING-ELECTRICALPLUMBINC-MECHANICAL CATEGORY Co
Andumet/Engleeer. U Lie.No: J F/
1
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: 1
_ lZs� DRi
LICENSED CONTRACTOR'S DECLARATION PERMITISSUANCE VJ�
I hereby affirmthat l am licensed under provisions o(Chapter 9(commene APPLIANCESRESIDENfIAL car JOB DESCRIPITON
IngwithScdion7000)of Divislon3ofthe Businesand ProfnslonsCodgandmy
License CWs L
se Is in(uB o and effect. PANELS
ueX 3 � '^V r
Date f_Y=q_(_Cmamavmr
ARCHITECTS EPIC RAT N 201-1000AMTS
q�++�ZCO I underatznd myplamahallbeuseel aspubliceemrcis. OVER1006AMPS SQ.FT.FLOOR AREA $/SQ.FT.
ir,L`j Licensed Pmfesiowl SIGNS ELECTRICAL 71( p 2—
�<iu OWNER-8
UILDER DECLARATION J `a
�.. 7 1 hereby affimnthat I am exempt fromthe Contractor'sLicense Law for the
SPECIALCIRCUIT/MLSC
Z
O Z t-O.:a following reason,(Section 7ml.5,Business and Professions Code:Any city or
county requlrvapertNtmronstmct,ilter,bnprove,dennlbh,or repair
TEMP.METER OR POLE INS).
I�
.� any structure prlorto its issuance,also requlreathe applicant for such permit to
file a signed state.m nt that he R licensed pursuant to the provisions of the I�WER DEVICES
Contractor's License Law(Chapter 9(rommencing with Section 7000)of Divi- SWIMMINGPOOL ELECTRIC
sion3oftheBuslnessandProfessionsCode)orth.the6exempt therefromand VALUATON
the basis for the alleged exemption. Any violation of Section 7001.5 by any OUTLWITCHESFlXTURFS EISSy, 1 0 D
•y0 applicant for a permit subjects the applicant to a civil penalty of not trove than L l S7a V
ddb$ five hundred dollars(S.ei00). I
I,as owner of the NEW RFSIDENI3AL ELECTR SQ.FT. SIO TYPECON'STRUCTION'
-••x ❑ property, my employees Is with r their
k"a cam(Sec.70K Iltldess.edo the rk.andthes Code:
The Contractorot oro((e Law
9 ❑ d for
sale(Sec 7614,Pueb�ess and Professions Code TM Contractors License Law
does not apply to an owner of property who builds or improves themon,and OCC GROUIa RES.UNITS
whoda"such workMm elf orthr°ugh hisownemployeas,provided that such
improvemenb are not intended oroffered forsale.If,however,the bulldingor TOTAL;
improvement issold withinoneyearofcompletio0.theownerbuBderwBl have
the burden of proving that hedid notbuild orimpreveforpurposeofeele.).. QTY, PLUMBING PERMIT FEE plppp 7pNE APN
4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE f�a.ryr
contractorsto construct the project(See.704q Busbus and ProfesslonsCode: 6�L(l
The Contractors License Law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such piejede with a
rIador(s)licensed pursuant to the Coroodor'sLicense Law. BACKFLOW PROTECT.DEVICE FEE SUMMARY
I am exempt under Sec. B&P C for this reason
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Dace RECEIPT X
[:]❑ b WORKMAN COMPLNSATIONDECLARATION RX �3.�P x� SCIjOOL TAX Y N_
the affirm that I have a certificate of consent to self-insure,or a RECEIPT p
3800,lab C)
unificateofWorkeri Compensaionlns mncewacertlfW copythenuf(Sec. GAS EA.SYSTEM-1 INC.40[TILETS PARK FEE Y N
Policy X RECEI'C X
Cam any GAS EA.SYSTEM-DVER4ffA) BUILDING DIV1510.�'FEES
�Certl(led copy b hereby famished. GREASE/INDUSTRL WASTEWTFRCEPTOR PLANCHECK FEE
�ead copy 6 filed with the city inspection division.
ViCERTIFICATE OF EKEMPTION FROM WORKERS' GREASE TR" PAID1�' Q
COMPENSATION INSURANCE SEWERSANTTARYSIORM EA 200ET Date Remipt#
Rhis union need not be romplded)(the permit V(Drone hundred dollars
I certifyifythat
(5100)oTR a AU
hat In the performance of thework for widen this pelt is Issued'
WATER HEATERW/VENT/ELECENERGY FEE Y—
N '
1 shall not employ any person In any manner so u to become subject t°the 11 �11 ❑ t
Workers Compensation Laws of California.Date WATER SYSTEM/TREATING PAID l��
O Z Applicant
Z O NOTICE TO APPLICANT.If,after ma king this Certificate o(Exemption,you NEW RESIDENTIAL PLMB. SQF . Date Recel N
should become Subject to the Workers''Compemat Ion provisions of the Labor - TOTAL:
-WW Code,you must forthwith comply with such provisions or this permit shallbe
> deemed mvaked. BUILDING FEE
lL
CONSTRUCTION LENDING AGENCY SEISMIC FEE as
1 hereby affirm Oat there V a mnstructlon lendingagency for the perform. ELEL FRIG FEE
O ance ofthe workfor which this permit V isswed(See 3097,Civ.C.) TOTAL:
V lender's Name PLUMBING FEE
IL Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iurti(ythatl have readthb applcationand xatethat thcabove infomation ��
S itcormet.Iagree to comply withal)city and countyordinances and state laws PERMIT ISSUANCE FEES PAID:
} N relating to building constroction,and hereby authorize representatives of this
F Z city to enter upon the above-mentioned property for Inspection purposes. �,- ALTERORADDTOMECH.
V — (We)agree to save,indemnify an d keep harmless the City of Cupertino 'w Date Receipt#
against llabillties,judgments,costs and expenses which may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City in consequenc fthegranit Alfthlsp it.
If GcAF!..4tf AIR HANDLINGUNIT(OVER IO,MOCFM) CONSTRUCTION TAX
gesture o(AppBcant/Contractor Data FxHAusT rlooD 6v/DUCp CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppllcant or future building occupant store or Mrad le haxardous HEATING UNIT(TO IDg000 JIM ,
material as defined by the Cupertino Municipa l Code,Chapter 9.12,and the _ Date Reeel tN
I lealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 1(1B4OOp R'C[T)
❑ Yes �f No TOTAL:
Will the zppilcant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) 'P""; DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Q+ litYManagement District?
Nt, BOILER-COMP PHP OR 100,DM BTU) eQ
4havercadthe hav�ousnute a6 nus m nbunderChapter6.95o( BOILER-COMP(OVLR100,000BIU) �a97�
the California Health&Safety Code,Sections 25505,75533 and 25334. I A f11�k
understand that if the building does not currently have a tenant,that it Emy NEWRESIDFNIIALMECH. SQ.FI. ,
responsibility to notify the occupant of the requirements which must be met Ry�,.Jg1.�•�
priortolsuanceofa Certific waoccupaney.
Owner or awhorlmd agent Date ISSUEDBY
TOTAL: CYJ
OFFICE COPY
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NOISIAIO NOU33dSNI
ONIl!l3dno 30 kilo